I hope Suzanne Mazzola's family hasn't gotten around to reading the anti-choice articles about her, because whether they sound like touching tributes or not, I can tell you, it's hard to grow up believing that your parent decided to die. It does things to people.

Earlier this month, Suzanne Mazzola, a 34-year-old woman, died in childbirth from a life-threatening condition diagnosed during her pregnancy. She left behind her husband of nine years and four children. I can’t tell you how sad it made me to read her story. Or to read this description of it by LifeNews writer Steven Ertelt:

Mazzola proved that there really is no greater love than laying down’s one life for someone else. The 34-year-old died last week after giving birth to her fourth child, a beautiful little boy named Owen.

Ertelt’s article implies that Mazzola deliberately chose to die instead of ending her pregnancy to save herself. Here’s what worries me about that: I feel that often, discussions of matters of faith fall too easily into frames of abstract right and wrong, and lose sight of the other reasons people involved may have for making decisions. We might talk about failings of faith, and forget to think about mental health. We talk about belief, and forget to think about peer pressure, or the importance of deep social ties, and how things we talk about can affect the people around us.

My own history gives me reason to find this particular way of describing Mazzola’s story very disturbing. Let’s go back 35 years.

At 5 years old, I was the last person my father had the strength to smile at before he died. He’d had one chance to live, and he wouldn’t take it because our church prohibited blood transfusions. God was going to bring him back in the resurrection any day now anyway, right?

Fast forward a few years. I needed emergency surgery, because my infected appendix went untreated long enough to cause full blown peritonitis: infection of the abdominal cavity. The procedure to treat it required a large incision and was very dangerous—but it almost didn’t matter. The doctors at the hospital I was checked into wouldn’t operate unless they could use blood if they thought they needed to. My mom and stepfather wouldn’t hear of it. But then, neither would I.

I agreed that I would just have to die if my doctors wouldn’t agree to operate without blood, because my father had given us all that example of perfect faith. Our church sermons were full of stories about people who died for our beliefs, and in our own household, my father had been just such a hero. I loved him. I wanted to be worthy of him. There wasn’t even a conversation, a question, a doubt. I was personally prepared to die before my tenth birthday if a doctor didn’t agree to operate without the possibility of a blood transfusion under any circumstance. Finally, at a different hospital, one did. And here I still am.

My dad couldn’t see a way to go on living as a person who’d violated the tenets of his faith. It was unthinkable to him. There’s a word for choosing to die. The word doesn’t matter. The fact of choosing to die matters for the people you leave behind. My father’s act was a social contagion so powerful that the child I was, scared as I was, thought nothing of imitating it. It was unthinkable to me to do anything else.

Now, the level of peer pressure that exists in fundamentalist faith communities is something I’ve seen no equivalent of in the more liberal and secular circles I’ve spent my time in since leaving my childhood faith. I don’t always relate to people who grew up in environments where they were told they’d be just as welcome no matter what they decided to do, as long as they were happy. And I think maybe they, in turn, don’t entirely relate to people whose private choices about things like whom to date or what medical procedures to have can cost them the goodwill of everyone they depend on. Love doesn’t mean the same thing to everyone.

Some opinions kill their carriers. Some stories are powerful carriers of such fatal opinions. The things my father learned at church likely killed him, and the pain his very untimely death caused did serious damage to each member of my family. The same beliefs almost killed me as a child. As an adult, again in need of emergency surgery, the beliefs of my Catholic health-care providers—beliefs that have led to the deaths of other women before—put me in danger again as my condition deteriorated in the course of waiting for a natural miscarriage before they would treat me.

Let’s write my dad’s story another way. A stubborn young man and his equally stubborn partner convert to the strict faith of Jehovah’s Witnesses, alienating themselves from their families. The sermons and literature they find include constant references to believers giving up their lives for the faith, and socializing with unbelievers is strongly discouraged. He leaves a promising career to go minister “where the need is greater,” and takes whatever menial work he can find in a small town where they know no one outside the local Kingdom Hall. He and his growing family build close ties in their new religion, one that disfellowships, or severs all social ties with, people who break the laws of the church. He gets sick, and he has two choices: break the faith for a chance to live, or die for certain. He chooses death.

If we weren’t talking about a matter of faith, we’d wonder if someone who chose so certainly to die had undiagnosed mental health issues. Wouldn’t we really have to ask whether or not my father was secretly relieved to have an honorable way out, if we saw him as a person, as opposed to a representative of a belief? Wouldn’t we have to wonder that about someone who recklessly threw his family into poverty for a new faith, who got so angry over the misbehavior of toddlers that many of my few memories of him involve being spanked, a man who chose to die in his mid-30s based on stories someone told him?

Of course, we take on varying levels of risk every day of our lives. Some people even take quite dangerous jobs—soldiers, police officers, firefighters. And yet, anyone would be worried about someone in such a profession who simply expected to die and wouldn’t try to save themselves if they could. We distinguish between the acceptance of risk and resignation to untimely death.

So it worries me tremendously when religious people in high peer-pressure communities start glorifying what they describe as a kind of voluntary martyrdom involving a common, but potentially dangerous, situation: pregnancy. There just aren’t many chances to die a hero in the course of an ordinary life, which could sound appealing to people suffering from depression, and that’s something people should be cautious in remembering. But what else would anti-choice people say when something happens that contravenes their routine assertions that pregnancy is no big deal?

To suggest that childbirth is ever safe and simple is disrespectful to the bravery of everyone who’s carried a pregnancy. It’s a risky enterprise even with trained medical support. “Woman dies in childbirth” is such a ubiquitous fictional trope that it’s almost invisible; it works because everyone knows that pregnancy can be deadly, even though most women can and should reasonably expect to survive the experience. It’s not a polite topic of conversation, but whoever you are, your mother risked her life to bring you into the world.

Even so, fundamentalist Protestant and Catholic cultures have been saturated for years with claims that pregnancy is never really dangerous. That’s why they’re often so outraged by having to include life and health exceptions to pass their odious abortion bans. The very idea of pregnancy as a dangerous health condition offends them: It takes the focus off the potential life and brings it back to the fully realized human being carrying the pregnancy.

Then a woman like Mazzola—by all accounts a loving spouse and parent—dies from pregnancy-related complications in her mid-30s. Lest she be proof that pregnancy can be dangerous, she has to be turned into a martyr for the faith, an example to hold up to others.

When I first read the LifeNews article, the way it was presented reminded me powerfully of stories of martyrdom told in the Kingdom Halls I attended as a child. Stories about Jehovah’s Witnesses going willingly to the gas chambers of the Third Reich for maintaining their faith, refusing to save their own lives through lies to repressive regimes who targeted members of the church, things like that. I know firsthand that glorifying stories of fatal self-sacrifice can kill people and devastate families in conservative and insular religious communities. Communities who might even share the anti-choice belief that abortion should be “unthinkable.”

I also know that undiagnosed or ignored depression is a dangerous thing. Postpartum depression, in the midst of a community that may fetishize motherhood and wifely obedience, is a hard thing even to admit to. Many devout people suffer in silence. Given that the explanation for things like the distressing, intrusive thoughts that more than 80 percent of new parents may experience is likelier to be demons than biology in some faith communities, if they do talk about their distress, the prescription is likely to be prayer, faith, and positive thinking. What might this story, when presented as LifeNews frames it, sound like to a depressed and overwhelmed mother facing a potentially dangerous pregnancy of her own?

Because whatever Suzanne Mazzola thought in life, now her situation is being used to glorify what’s being portrayed by anti-choice activists as a choice to die by refusal to consider abortion as a treatment option.

Though I did some checking, and regardless of what her position on abortion might have been, that’s probably not what Mazzola thought was going on. From what’s been reported, she was scared of what might happen, and I think most people would have been were they in her shoes, but as a friend of hers told the SunSentinel, no one expected this outcome.

There are some pregnancy complications for which doctors will automatically, if they’re not practicing in a Catholic hospital, recommend abortion because it may reduce or eliminate the risk to the mother’s life. According to medical professional groups, placental accreta, Mazzola’s condition, in which the placenta has burrowed into the uterine lining, is not necessarily one of them. Both abortion and delivery pose the risk of serious complications, and Mazzola reportedly had a serious form of the condition. The American Congress of Obstetricians and Gynecologists (ACOG) recommends the following as a general management guideline: Wait until near the usual point of fetal lung maturity, usually around 34 weeks but customized to the patient, and perform a scheduled, preterm cesarean section delivery with either a resection of the uterus or a hysterectomy, and to be prepared for the onset of serious bleeding. ACOG says that maternal mortality can be as high as 7 percent for placenta accreta patients, which is many times the usual rate, but it’s still a 93 percent chance of survival.

Mazzola went in at 35 weeks for a scheduled c-section, which is very close to the treatment recommendation that someone would get from recent ACOG guidelines. Tragically, her blood loss was too severe, though the availability of 15 doctors in the operating room for her treatment suggests that the hospital staff were prepared to do everything they could, doubtless in consultation with the family. That doesn’t sound to me like giving up. It sounds like a case where someone who wanted very much to live couldn’t be saved from a dangerous health condition. That happens sometimes, even with the best medical treatment.

In other words, given a frightening diagnosis during a wanted pregnancy, Mazzola appears to have hoped for the best and done exactly what most doctors would have advised for the best chance of survival. To rewrite this as if it were some kind of deliberate choice to go to her death—which the framing of Ertelt’s article implies—appears to be a substantial misreading of usual medical practice in treating placental accreta in the absence of other emergency complications.

So I hope Mazzola’s family hasn’t gotten around to reading that article, because whether it sounds like a touching tribute or not, I can tell you, it’s hard to grow up believing that your parent decided to die. It does things to people.

And it’s dangerous to suggest to bystanders that, given a choice, the best decision in any circumstance is to willingly and unnecessarily choose death. You never know if the person reading is suffering from depression and might be looking for a way out. It’s frightening to contemplate the damage such words can do.

What really matters to me in writing this is that there might be someone out there facing a dangerous medical condition, for which the treatment is something that your faith community disapproves of. As the child of someone who made a choice like this and knows how very hard it is, I want to tell you something:

You are important to your family and friends. Your loved ones will miss you every day for the rest of their lives if anything happens to you, and they need you. Even the ones you butt heads with all the time, or the ones you think have it all together. They need you. Not the memory of you, or the example of you, but really, actually, you. You, in reality, are better for the people who care about you than any sainted story and photograph.

You matter for your own sake. Even if you are a woman, and you can potentially do this amazing thing where you create an entire other person, you’re already enough. I hope you’ll at least consider taking that under advisement. Women’s lives are valuable.

You matter even if you don’t understand why you keep thinking horrible things that make you ashamed, or hate yourself so often that it feels like a second job. These are hard things to live through, I know, but you don’t have to bear it alone. If you’re in such a bad place that it seems reasonable to you that it might be God’s will for you to go, that’s probably not God talking. No matter what you believe, this is the one and only human life you can guarantee you’re going to get. Even if you and I agree about nothing else at all, I’d consider the world diminished by your death.

You deserve to live. I hope you will consider fighting to continue doing that. I hope you will try to stay with us.

]]>http://rhrealitycheck.org/article/2015/02/26/framing-suzanne-mazzolas-death-childbirth-martyrdom-disturbing-dangerous/feed/215Social Conservatives Step Up Efforts to Shame You Over How You Perform Womanhoodhttp://rhrealitycheck.org/article/2015/02/23/social-conservatives-step-efforts-shame-perform-womanhood/?utm_source=rss&utm_medium=rss&utm_campaign=social-conservatives-step-efforts-shame-perform-womanhood
http://rhrealitycheck.org/article/2015/02/23/social-conservatives-step-efforts-shame-perform-womanhood/#commentsMon, 23 Feb 2015 19:47:27 +0000http://rhrealitycheck.org/?p=54059

Social conservatives have been getting more obvious about bullying women into accepting their self-sacrificing, self-effacing model of womanhood. They're having to get louder because fewer women are listening.

Two pieces from the anti-choice hub LifeNews over the past week tell us oh so much about the gender politics of that movement right now: that women should be willing to sacrifice everything, up to and including their lives, to satisfy their ideal of how women should be.

Using myself as an example and shoring it up with some cheeky language, I’d argued that women should not feel obliged to give in to conservative guilt-tripping about how we should curtail our own happiness to fit their notion of a “model” woman. The idea that women should have that level of autonomy is treated as so self-evidently evil at LifeNews that the site simply quotes me, at length, and expects its audiences to be horrified.

Not to hammer this point too hard, but it’s telling what parts of my piece they found appalling enough to focus on: a passage where I point out that having a baby is very disruptive and, since I like my life as it is, I don’t feel inclined to disrupt it. LifeNews ended its post by quoting me saying, “I choose me.” Evidently, those are the most horrifying words a woman could utter.

The issue here, to be very clear, is not to sit in judgment of Mazzola, who was facing what no doubt felt like an impossible choice. The issue here is that LifeNews is romanticizing death in childbirth as the highest aspiration of womanhood and “no greater love.” As Jessica Valenti noted at TheGuardian, the situation sounds complex, but it is being flattened out in service of the idea that “the most important, beautiful thing [women] can do is perish.”

If you take these two stories together, it becomes clear that LifeNews, and the extreme social conservatism it represents, is pushing a very strong message: Women should be willing to give up everything—your ambitions, your comforts, your happiness, your presence in your children’s world, your very life—to conform to an ideal. It’s an ideal of womanhood as martyrdom, in which women give and give with no thought for themselves, where motherhood is the highest calling and marriage is about being a helpmeet and not a partner.

It used to be easier for social conservatives to wax poetic about “life” and “family” and let the underlying desire to control women go unspoken. But in recent years feminism has risen to the top of popular consciousness, demonstrating—particularly to young women—that there are a number of appealing ways to be a feminist and to define what their lives should be like. Because of this, social conservatives seem to feel more pressure to spell out in rather unsubtle terms exactly what they want women to be, whether the women in question like it or not.

Of course, this desire to control women’s behavior isn’t limited to our reproductive rights. Take this piece by Mary Eberstadt, published Thursday in The National Review. The article, titled “Jailhouse Feminism,” argues that feminists’ lack of interest in scolding young women to be more ladylike makes feminism an invalid ideology. Eberstadt is miffed that feminists are often “aggressive and angry” and even—gasp!—use four-letter words sometimes, calling this “the potty-mouthed bile-o-rama.”

Ironic uses of the word “slut” and “bitch” particularly draw Eberstadt’s ire. “Repurposing the word, it’s argued, will protect women from the damage done by ‘slut-shaming,’ or criticizing women for their sexual conduct. By ‘women,’ of course, is meant sexually active women of a certain type, the kind who in a different age were known as, well … you know,” she complains. Given that Eberstadt herself evidently wishes she could just call women of “a certain type” “sluts,” it appears “potty-mouthed” language is fine, so long as it’s being used to hurt and shame women. But if women themselves use it to free themselves, that’s crossing the line.

Overall, feminists’ “approach takes for granted the sexual revolution’s first commandment, which is that any such act ever committed by any woman is by definition beyond reproach,” she writes, conflating feminism and the sexual revolution. It’s an odd statement, seemingly suggesting that if you allow women to enjoy sex without shaming them for it, you might as well allow them to murder and pillage.

Closer to the truth: Feminists believe women’s moral worth is determined by how they treat people, including themselves, and not by whether they cross some arbitrary, ever-shifting line into liking sex too much.

Eberstadt goes on—because of course she does—offering to diagnose feminists from afar as pathetic attention-seekers and the usual misogynist pablum. But more telling are her rote references to Miley Cyrus, Beyoncé, Lena Dunham, Fifty Shades of Grey, Rihanna, Ciara, and even Britney Spears, whom she identifies as a “feminist singer.” It is true that pop culture of recent years has been shaped in large part by the urge, sometimes explicitly feminist and sometimes not, to let women express themselves with more of the freedom previously only allowed to men. While Eberstadt displays poor understanding of the specifics, her sense that young women have a plethora of role models of liberation to look up to isn’t really off-base.

On this fact, there is clearly broad agreement between conservatives and feminists: It’s become much, much harder to terrorize women with messages about how they are shameful, even evil, people if they do things like make decisions about their health or their futures, enjoy sex, or express their opinions. The only real dispute is over whether or not this change is a bad thing.

Women will continue to die far too young in South Sudan if public health strategies fail to reach youth before they become sexually active, and policies fail to address the family planning needs of communities.

According to Joy Mukaire, executive director of the Christian Health Association of Sudan (CHAS), a network of Christian health-care providers, health training institutions, and advocacy groups, there are a number of factors keeping women from planning pregnancies at times that would be optimal for their health—a critical strategy in reducing maternal deaths.

A major problem for women and girls is the common practice in South Sudan of early marriage, with girls as young as 13 marrying much older men, often becoming a second or third wife. There is currently no law to protect young girls from this practice or no minimum age to marry in the nation. These early marriages result in pregnancies before girls are physically mature, putting them at risk for obstructed labor and other complications. “South Sudan is a patriarchal society,” explains Mukaire. “This environment, coupled with strong cultural factors acts as a disincentive to the education of girls. The 2010 Sudan Household Health Survey revealed very low literacy rates, with only 11.8 percent of women and 36.8 percent of men aged 15 to 49 able to read and write. We have to continue to remind those in charge that the state has the legal obligation to respect, protect, and fulfill the reproductive rights of women.”

Furthermore, Mukaire says the South Sudanese government is presently overwhelmed with competing social, political, and economic development priorities, and there are no definite strategies to embrace the importance of ensuring that girls delay marriage and pregnancy and enroll and stay in primary education. As a result, young girls do not know how to delay pregnancy until their bodies are ready to carry and deliver a child, and even adult women in South Sudan have little knowledge of how to safely space pregnancies.

Fortunately, the Ministry of Health recently approved the National Family Planning Policy to provide a framework and guidance for the development and delivery of family planning services that Mukaire hopes will lead to greater and more equitable access of services and improved quality and responsiveness to the family planning needs of all clients. “While the policy does not commit to full-fledged family planning advocacy and service goals, this is the first step to encouraging the political environment to recognize family planning as one of the major strategies in reducing a high maternal mortality rate,” explains Mukaire. She also believes family planning education and services are activities trusted social service delivery systems like faith-based organizations should scale up. Research shows that a child born three to five years after the birth of a sibling is about two and one-half times more likely to survive than children born closer together.

To help families achieve healthy birth spacing, alongside public sector efforts, CHAS member organizations provide oral contraceptives, condoms, and injectable contraception. According to Mukaire, IUDs (intrauterine devices), Norplant hormonal implants, and permanent surgical family planning methods are not yet available in South Sudan.

While steps are being made to address the high maternal mortality rate, women will continue to die far too young in South Sudan if public health strategies fail to reach youth before they become sexually active, and policies fail to address the family planning needs of communities. Bringing together the government with the private sector and the powerful reach of the faith community in South Sudan can go a long way toward saving the lives of thousands of women and girls.

Developing nations like Kenya have not experienced the overall decrease in maternal mortality enjoyed across the globe. More needs to be done to address the impact of maternal death on families and communities.

Even though Naimah* had sought care a couple of times during her pregnancy at a clinic near her village in western Kenya, she died during childbirth. Her baby lived for a short period afterward before eventually dying, too.

Naimah’s husband, Kareem*, was devastated. His wife had handled everything in their home, from taking care of the children and planting and harvesting crops, to managing all of the household purchases. Naimah also operated a small business outside of her home, which brought in extra money for her family.

The loss felt by Kareem, the surviving six children, and the rest of the family was widespread and overwhelming. Their experience in the aftermath of Naimah’s death, however, is not uncommon in developing countries; it is illustrative of the typical economic and social costs of maternal mortality, which will be a major topic of discussion today at the Women Deliver conference in Kuala Lumpur, Malaysia.

Maternal deaths have reduced by nearly half since Millennium Development Goal 5—which aims to improve maternal mortality—was established, but there is still a ways to go to achieve this goal by 2015. It’s possible to prevent more deaths and eliminate their affiliated costs, but doing so requires well-coordinated approaches that straddle multiple sectors.

ICRW is working to better understand the ripple effect maternal death has on families through a groundbreaking study in Nyanza Province, Kenya, that is examining the immediate and long-term economic, emotional, and social costs and consequences of maternal mortality. Working in partnership with Family Care International (FCI) and Kenya Medical Research Institute (KEMRI), the ICRW study is one of a few examining maternal mortality costs; most research efforts to date have focused on understanding the causes of maternal mortality and designing interventions to address it.

Preliminary findings from our research suggest that a family often will spend considerably more on a funeral—burial, food for visitors, etc.—than other non-food expenses such as rent and school fees for the entire year. Our early data also show that after a maternal death, families immediately reassign to other family members tasks that were handled by the deceased. It is a necessity, but also a disruption on relatives’ routines and children’s studies.

In the case of Naimah, her death resulted in a complete overhaul of how her home had operated. Kareem lamented the loss of companionship that followed his wife’s passing, especially her input on household-related decisions. Meanwhile, Naimah’s children had to focus more on household chores such as fetching water, caring for livestock, and doing laundry, than on their schoolwork, potentially affecting their chances of completing their education. Other relatives in the home had less time to pursue income-generating activities, and instead became consumed with completing Naimah’s household tasks.

Developing nations like Kenya, where Naimah’s family lives, have not experienced the overall decrease in maternal mortality enjoyed across the globe. Although more Kenyan women are using skilled health workers to deliver their babies, the number of mothers who have died as a result of childbirth has increased since 1990. That year, Kenya reported a maternal mortality ratio of 360 per 100,000 live births, according to the World Health Organization; in 2010, this number jumped to 530 per 100,000 births.

Given the data, it is clear that more needs to be done to address the impact of maternal death on families and communities, and design effective approaches to help them navigate the aftermath. We believe that capturing data on the disruptions and the social and economic costs of maternal death will arm programmers and funders with crucial information to better direct investment in and development of solutions to address maternal mortality.

According to a new report, the United States has the highest first-day death rate in the industrialized world. Addressing this and related problems will require comprehensive efforts to reduce pervasive economic, social, and health disparities.

In the United States, an estimated 11,300 babies die each year on the day they are born, according to a new report from Save the Children. The United States has the highest first-day death rate in the industrialized world, and given its large population it has 50 percent more first-day deaths than all other industrialized countries combined. The alarming report has clear implications for U.S. policy, particularly the importance of investing in and expanding the reach of programs like Medicaid and Title X that make affordable pregnancy-related care and family planning services available to millions of women who are otherwise unable to obtain such care.

First-day deaths have many contributing factors, according to the report, including preterm, unplanned, and teen births. One in eight U.S. babies—a total of over half a million births each year—are born prematurely, and U.S. preterm births rank second only to Cyprus in the industrialized world. The report also notes that half of all U.S. pregnancies are unintended and that the U.S. adolescent birth rate is the highest among industrialized countries—with teenage mothers tending to be poorer, less educated, and receiving less prenatal care than older mothers.

Clearly, a complex problem like the high rate of U.S. infant deaths—as well as the closely related challenge of the high U.S. maternal death rate—requires comprehensive efforts to reduce pervasive economic, social, and health disparities. Improving access to high-quality, affordable maternity care for all women regardless of income or background has to be a major national priority. Another key component of a broad-based approach is making effective family planning available to every woman who needs it, a proven intervention that offers direct and positive effects on newborns’ and mothers’ health. According to U.S. and international studies, there is a causal link between proper birth spacing and three major measures of birth outcomes: low birth weight, preterm birth, and small size for gestational age.

In addition, according to a 2008 literature review, numerous U.S. and European studies have found an association between pregnancy intention and delayed initiation of prenatal care. This is partly because women are less likely to recognize a pregnancy early if it is unplanned. Early recognition of pregnancy also affects the frequency of prenatal care visits. Furthermore, compared with children born from intended pregnancies, those born from unintended pregnancies are less likely to be breast-fed at all or for a long duration. Breast-feeding, in turn, has been linked with numerous positive outcomes throughout a child’s life.

Contraception has also been the main driver behind declines in the U.S. teen birth rate, which reached a record low in 2010. The U.S. teen birth rate—while still the highest among industrialized countries—has declined for nearly two decades, and the 2010 rate represents a 44 percent drop from the 1991 rate. Likewise, contraception’s impact on unintended pregnancy may also be seen in the significant benefits of publicly funded family planning services. Together, the services supported by Medicaid, Title X, and other public programs help women avoid 1.94 million unintended pregnancies each year, which would otherwise result in 860,000 unplanned births and 810,000 abortions. In the absence of this public effort, levels of unintended pregnancy would be nearly two-thirds higher among U.S. women overall and among teens, and close to twice as high among poor women.

As the Save the Children report underscores once more, it is crucial to protect and invest in the programs that are needed to ensure that all women, regardless of income or background, can access the affordable care they need to have healthier pregnancies and births. Ideological and fiscal attacks against these programs are not only counterproductive, but threaten to worsen what is already a severe crisis for U.S. women and newborns.

]]>http://rhrealitycheck.org/article/2013/05/10/family-planning-is-key-to-healthy-pregnancies-and-births/feed/1You Can’t Have it Both Ways: The Interpretation of Catholic Health Policy and the Consequences for Pregnant Womenhttp://rhrealitycheck.org/article/2013/01/22/interpretation-catholic-health-policy-and-consequences-pregnant-women/?utm_source=rss&utm_medium=rss&utm_campaign=interpretation-catholic-health-policy-and-consequences-pregnant-women
http://rhrealitycheck.org/article/2013/01/22/interpretation-catholic-health-policy-and-consequences-pregnant-women/#commentsTue, 22 Jan 2013 20:36:25 +0000

As a committee of the Irish Parliament considers proposals to offer limited legal abortion in Ireland, this paper explores how these issues came together around Savita Halappanavar's death, the interpretation of Catholic health policy and the consequences for pregnant women.

“There is only one way to be sure a woman’s life is at risk, that is, after she dies.” —Christian Fiala, 2012

In 1987, the year the first Safe Motherhood Initiative was launched by the World Health Organization (WHO), there were more than half a million maternal deaths annually. The women who were dying were often anonymous and their deaths never recorded or studied. They were mainly from poor and often rural backgrounds in developing countries, such as India. A study in India published in 1999 comparing 100 maternal deaths in a Rajasthan hospital in 1983-85 to 100 in 1994-96 found that: “Most of the women who died in hospital in 1994-96 would have died at home in the earlier decade.”1 What had changed was that they had reached a hospital and were therefore no longer anonymous, but they were still overwhelmingly women living in poverty with little or no access to skilled pregnancy and delivery care.

Contrast this with the death of Savita Halappanavar on 28 October 2012, a dentist from a privileged background in India, who miscarried 17 weeks into a very wanted pregnancy and died in the maternity ward of a hospital in Ireland, a country with a very low maternal death ratio.2 Savita’s death was anything but anonymous; her name and photograph circled the globe within days of her death and sparked street demonstrations and protests, not only across Ireland but also in many other parts of Europe and in India. Six weeks later, articles and blogs about her death continued to be published in many countries, demands by her husband for a maternal death audit were headline news, and the Irish government has been forced to consider the effects of her death for the law, health policy and the Constitution of Ireland.

Savita’s death became iconic for a number of reasons. First, preventing maternal deaths has been a global priority since 1987 when the first WHO Safe Motherhood Initiative was launched. Since 2000, reducing maternal deaths by 75 percent by 2014 has been the main target of Millennium Development Goal No.5, and since 2010 it has been one of five main goals of the UN Secretary-General Ban Ki-Moon’s Global Strategy on Women’s and Children’s Health. Hence, maternal deaths have started to be a news item globally, with journals like Reproductive Health Matters carrying studies and the media in many countries where deaths remain frequent, reporting successes and failures to reduce deaths, and individual stories regularly.

Secondly, holding governments accountable for their failure to provide the required services, both antenatal and delivery care and emergency obstetric care, to prevent avoidable maternal deaths has become the subject of public protests by women’s rights advocates, of court cases, including in India, and of hearings by human rights bodies, particularly CEDAW, examining individual cases and making policy recommendations to governments.3

What was different about Savita’s death, however, was the fact that it was also about whether and when to terminate a pregnancy when it is not viable and the woman’s health and life are at risk, and how that intersected in Savita’s case with individual health professionals’ interpretation of Catholic health policy and the law on abortion in Ireland.

As a committee of the Irish Parliament considers proposals to offer limited legal abortion in Ireland, this paper explores how these issues came together around Savita’s death, the interpretation of Catholic health policy and the consequences for pregnant women.

Preventing maternal deaths as global policy

Maternal deaths, especially in countries where they remain frequent, are getting more and more media coverage. The Millennium Development Goals have made countries with continuing high maternal mortality ratios4 conscious of their shortcomings, and civil society organisations are beginning to pursue justice and even compensation in individual cases.

In India, for example, a petition for legal redress was filed in the Delhi High Court in the case of Shanti Devi, who died in childbirth in January 2010 after two high-risk pregnancies in which she received delayed and insufficient care. With the first of these two pregnancies, she fell down the stairs and afterwards could no longer feel the baby moving. Induction of the pregnancy was delayed until she required intensive care which, when she finally received it, was inadequate. With her health still very precarious, she became pregnant again six months later, went into labor prematurely at seven months, delivered the baby at home without a skilled birth attendant or any medical assistance, and within an hour after delivery, began hemorrhaging and died. This case ensured that the Court took into account not just the individual death but also the constitutional and human rights obligations of the central government of India.5

Some communities where women are at high risk because of the lack of routine and emergency obstetric care are also beginning to protest against maternal deaths. One such event took place in Uganda where, in May 2011, hundreds of concerned citizens and health professionals stormed the Constitutional Court in Kampala, Uganda, protesting the deaths of women in childbirth, in support of a coalition of activists who took out a landmark lawsuit against the government over two women who bled to death giving birth unattended in hospital.6

Another example from India comes from Barwani district, Madhya Pradesh, India, where there were local protests against 27 maternal deaths in the period from April to November 2010. In January 2011, an NGO fact-finding team found an absence of antenatal care despite high levels of anaemia, absence of skilled birth attendants, failure to carry out emergency obstetric care in obvious cases of need, and referrals that never resulted in treatment.7

Events like these are making the governments concerned highly sensitive to criticism. As an upper middle-class woman, Savita Halappanavar would have been highly unlikely to die in India from the appalling treatment experienced by Shanti Devi or the tribal women in Barwani. Yet, ironically, the Indian government was among the first to criticise those in Ireland who failed to prevent Savita from dying. For example, India’s ambassador to Ireland said that Mrs Halappanavar may be alive if she had been treated in India.

Emergency obstetric care, termination of non-viable pregnancies and Savita’s death

Whether the details of the maternal death audit in Savita’s case will be made public, as Savita’s husband demanded in the weeks following her death, is uncertain at this writing. It is widely accepted by the medical profession that maternal death audits must remain confidential in order to have the desired outcome—open examination of the causes of death and the actions that need to be taken to prevent such a death in future, if such a death is indeed preventable. This is the basis on which the United Kingdom Confidential Enquiries into Maternal Deaths have been conducted every three years and reported,8 and the process followed for these enquiries has been a model for other countries. There is an assumption in these cases that the individual health professionals involved acted in good faith, and the point is therefore to ensure that any mistakes made are avoided in future, not to punish people for making them. This is quite different from addressing medical malpractice.

Savita’s husband may or may not have understood why such audits are confidential when he demanded that the enquiry into her death be carried out in public, but his demand, according to the newspapers, was because he believed the doctors involved may have been covering up information, at least in terms of what they were willing to say to him and his solicitor.

In Savita’s case, and in others summarised below that are similar, the question of whether or not the deliberate decision not to terminate the pregnancy does constitute malpractice is highly relevant.

Part of the treatment required to save Savita’s life, which should have been carried out without delay, was the evacuation of her uterus to terminate the pregnancy. She was 17 weeks pregnant. Because her cervix was fully dilated, the pregnancy was no longer viable, that is, there was no way for treatment to make it possible for the pregnancy to continue long enough for the baby to become viable. Moreover, had the baby been born alive at 17 weeks, it would not have survived. Thus, only Savita’s health and life were at stake, as only she might have been saved. This was not, apparently, how Savita’s doctors saw the situation, or at least not what determined what action they took. Based on what was reported in the media, termination of the pregnancy appears to have been delayed beyond the point where her death may have been prevented because there was still a fetal heartbeat.9

But why?? What appears to be the answer arises from the reported statement by the doctors involved in Savita’s case that “this is a Catholic country” and in other cases reported in the media afterwards of direct reference to personal or hospital-wide interpretation of what doctors and nurses believe to be Roman Catholic health policy as regards treatment of miscarriage by Catholic health professionals.

“Evacuation of the uterus” is another way of saying “induction of abortion” or “termination of pregnancy” and this is where the problem lies, even though this was a wanted pregnancy that required an emergency obstetric response. Termination of pregnancy to save a woman’s life is legal in Ireland under the Offences against the Person Act 1861, and indeed in all but five countries in the world. Termination to save the woman’s life should be understood to mean to prevent a pregnancy from becoming life-threatening before it is already life-threatening. One would have thought that includes termination to complete an inevitable miscarriage and to end an unviable pregnancy, both of which could easily become septic, as well as termination when the woman has or develops a life-threatening illness while pregnant. However, there is nothing in writing that specifies what “termination of pregnancy to save a woman’s life” actually means, nor when it applies.

This was made even more complicated in Ireland since a 1983 Constitutional amendment, whose aim was to prevent termination of pregnancy ever becoming legal or indeed ever carried out, which states: “The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.” (Article 40.3.3, 1983).

Savita’s case and others before it have brought this lack of clarity to light. For example, according to a report in Wikipedia, an Irish woman named Sheila Hodgers became pregnant in 1983, one year after surgery for breast cancer and while still on treatment. The Wikipedia text states: “Since the anti-cancer drugs she was taking could harm the fetus, she was stopped from taking them. Hodgers began experiencing severe back pains and could hardly stand. Her husband urged the hospital to induce her pregnancy or perform a caesarian but they refused as it would damage the fetus. They also refused painkillers. The hospital had to abide by ‘The Bishop’s Contract’, a code of ethics drawn up with the Catholic Church.” Both she and the baby died soon after the birth. In 2007, a 17-year-old known as Miss D had an anencephalic (non-viable) pregnancy and went to the Irish High Court to stop the Health Service Executive from preventing her from travelling to obtain an abortion. The High Court ruled that she had a right to travel. Ireland has been supposed to develop policy and guidance on these matters for many years, and especially since a directive by the European Court of Human Rights arising from a case heard in 2010, in which a woman with a rare form of cancer had gone to the UK for an abortion to protect her health but argued that she should have had the right to an abortion in Ireland. The Court held in her case that there had been a “failure to implement the existing Constitutional right to a lawful abortion in Ireland.” Thus, clarifying the law on abortion in Ireland had long been an issue in Ireland when Savita died. Her death became the subject of public protest by those angry at Ireland’s failure to act on the European Court’s directive, and especially those supporting women’s right to abortion, rather than as a failure to carry out a life-saving emergency obstetric procedure. Yet the two are intimately linked.

In January 2013, in evidence to the government committee considering, at writing, what to do about the law in Ireland, three experts—Dr Jennifer Schweppe from the University of Limerick, Ciara Staunton from NUI Galway, and Dr Simon Mills of the Law Library—gave evidence that they had prepared independently. Each of them said that a Supreme Court ruling in the case Roche v. Roche in 2009, delivered by Susan Denham, who has since become the Chief Justice, meant that if a fetus cannot survive beyond pregnancy it does not enjoy the protection granted in the Irish Constitution to the “life of the unborn.”

What is Roman Catholic policy on termination of pregnancy as part of emergency obstetric care in cases of risk to the woman’s life?

A statement issued in November 2012 by the Standing Committee of the Irish Catholic Bishops’ Conference appears not to contradict the interpretation of Irish law above:

“The Catholic Church has never taught that the life of a child in the womb should be preferred to that of a mother. By virtue of their common humanity a mother and her unborn baby are both sacred with an equal right to life.

Where a seriously ill pregnant woman needs medical treatment which may put the life of her baby at risk, such treatments are ethically permissible provided every effort has been made to save the life of both the mother and her baby.

Whereas abortion is the direct and intentional destruction of an unborn baby and is gravely immoral in all circumstances, this is different from medical treatments which do not directly and intentionally seek to end the life of the unborn baby. Current law and medical guidelines in Ireland allow nurses and doctors in Irish hospitals to apply this vital distinction in practice while upholding the equal right to life of both a mother and her unborn baby.”

However, the requirement “to uphold the equal right to life of both a mother and her unborn baby” is the crux of the problem, because in a case like Savita’s and many others, the mother and fetus do not have an equal chance of survival. Catholic policy signally fails to acknowledge this and pronounce on it, to women’s great detriment. This text appears to support treating the woman to save her life, but it is highly equivocal, precisely because it still insists on opposition to all abortions.

Historically, in the United States, the Ethical and Religious Directives for Catholic Health Care Services of the United States Conference of Catholic Bishops, first published more than 60 years ago, aimed to ensure strict obedience to Catholic principles by all employees of Catholic-owned hospitals, without local variation. The 5th edition (2009) states that: “abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted.” In regard to cases such as Savita’s, it says only that:

“47. Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.”

On the basis of this statement, there would appear to have been no need to delay the evacuation of the uterus in Savita’s case because the fetus was not viable. However, a fetal heartbeat, indicating the fetus was alive, appears to have made all the difference— because it forced the individual medical professionals to decide, from a Catholic policy perspective, whether the death of the fetus was “directly intended” or not. This uncertainty, a direct result of this policy, was fatal for Savita and is potentially fatal for other women.

The authors of a 2008 study of provision of treatment for miscarriage by obstetrician-gynaecologists in Catholic-owned hospitals in the USA, describing best medical practice, state:

“According to the generally accepted standards of care in miscarriage management, abortion is medically indicated under certain circumstances in the presence of fetal heart tones. Such cases include first-trimester septic or inevitable miscarriage, pre-viable premature rupture of membranes and chorioamnionitis, and situations in which continuation of the pregnancy significantly threatens the life or health of the woman. In each instance, the physician must weigh the health impact to the woman of continuing the pregnancy against the potential viability of the fetus.”

The authors go on to say, however, that the manual of Catholic hospital ethics committees, which the doctors use to help them interpret and apply the Catholic directives states: “The mere rupture of membranes, without infection, is not serious enough to sanction interventions that will lead to the death of the child.”10 Because the manual of Catholic hospital ethics committees is probably considered the more authoritative source by these doctors, uterine evacuation may be carried out only after a woman becomes ill.

Their interviews with six US obstetrician-gynaecologists working in Catholic-owned hospitals found that in spite of the Bishops’ guidance, there were cases where, in managing miscarriages, Catholic-owned hospital ethics committees had denied approval of uterine evacuation while a fetal heartbeat was still present, forcing the physicians to delay care or refer the woman elsewhere. Some physicians intentionally violated this restriction because they felt patient safety was compromised. Here is what they write about three of their reports:

One reported that at her Catholic-owned hospital, “approval for termination of pregnancy was rare if a fetal heartbeat was present (even in “people who are bleeding, they’re all the way dilated, and they’re only 17 weeks”) unless “it looks like she’s going to die if we don’t do it.”

Another reported: “She was very early, 14 weeks. She came in… and there was a hand sticking out of the cervix. Clearly the membranes had ruptured and she was trying to deliver… There was a heart rate, and [we called] the ethics committee, and they [said], “Nope, can’t do anything.” The woman was then sent 90 miles away to another hospital for treatment.”

Still another reported: “I’ll never forget this; it was awful—I had one of my partners accept this patient at 19 weeks. The pregnancy was in the vagina. It was over… And so he takes this patient and transferred her to [our] tertiary medical center, which I was just livid about, and, you know, “we’re going to save the pregnancy”. So of course, I’m on call when she gets septic, and she’s septic to the point that I’m pushing pressors on labor and delivery trying to keep her blood pressure up, and I have her on a cooling blanket because she’s 106 degrees. And I needed to get everything out. And so I put the ultrasound machine on and there was still a heartbeat, and [the ethics committee] wouldn’t let me because there was still a heartbeat. This woman is dying before our eyes. I went in to examine her, and I was able to find the umbilical cord through the membranes and just snapped the umbilical cord and so that I could put the ultrasound—“Oh look. No heartbeat. Let’s go.”

The authors conclude that:

“…although Catholic doctrine officially deems abortion permissible to preserve the life of the woman, Catholic-owned hospital ethics committees differ in their interpretation of how much health risk constitutes a threat to a woman’s life and therefore how much risk must be present before they approve the intervention.”

These interpretations appear to be operative in other countries with Roman Catholic influence as well. The Dominican Republic is one of the five countries globally where abortion is not permitted legally on any grounds, even to save the life of the woman. Although this should not apply in cases of emergency obstetric care, it did apply in August 2012 in the case of a 16-year-old Dominican girl with leukaemia who died of complications caused by a miscarriage. She had been diagnosed as suffering from leukaemia in early July that year, when she was only a few weeks pregnant. At that time, she was prevented from having a therapeutic abortion—as recommended by health professionals—because it was believed to be against the law. Chemotherapy was also delayed as doctors were concerned it would harm the fetus.

Similarly, the International Campaign for Women’s Right to Safe Abortion published a solidarity request in December 2012 in support of a Costa Rican woman called Aurora who was carrying a non-viable pregnancy with multiple, severe fetal malformations, which were identified in the first trimester. For almost five months, the report said, she suffered from severe back and abdominal pain and was unable to work. A live birth was impossible. Yet no one in the country could be found who would induce labour to bring the pregnancy and her suffering to an end. Only when she was 29 weeks pregnant did her waters break, and a caesarean section was carried out. In response to protests by a women’s rights group, Ileana Balmaceda, described as the highest authority in Costa Rica’s public health system, said that the country’s laws did not allow abortion in this kind of case (Personal communication, 4 January 2013).

Savita’s case has also led women in Ireland who survived similar experiences to speak out. The Irish Examiner reported on 16 November 2012 that on RTÉ Radio’s Liveline, five women phoned in who faced similar situations to Savita Halappanavar. All five were 15 to 20 weeks’ pregnant when the incidents occurred in hospitals from 1997 to 2004. Here is what one was reported as saying:

“Jennifer said that in 2003 when she was 16 weeks’ pregnant, she started bleeding and went to her local hospital. ‘All the nurses inside [the unit] just started crying uncontrollably. They said there was no hope for the baby and they couldn’t understand why I hadn’t miscarried. There was no … fluid [around the fetus], he had one kidney, fluid on his brain. But there was a heartbeat. They kept listening.’ Jennifer said GPs and four consultants met her separately after work in their own time for scans, only to tell her ‘you need to make a decision immediately’ due to the impact on her health. She said one said to her mother: ‘I know what I would do if it was my daughter, you need to read between the lines. You need to do it urgently.’ ‘I went to see my GP at 11pm at night.’ Her mother travelled with her to Britain [for a termination].”

Another case reported in 2010 regarding a Catholic-run hospital in the state of Arizona in the United States led the head of the hospital and of the hospital ethics committee to reach exactly the same conclusion:

“…The case involved a woman in her 20s with a history of abnormally high blood pressure that was under control before she became pregnant. Doctors were concerned about the extra burden that pregnancy would place on her heart. She was constantly monitored during the early stages of pregnancy when tests showed that her condition was deteriorating rapidly… Before long her pulmonary hypertension had begun to seriously threaten her life. The woman was informed by doctors that the ‘risk of death’ was high if she continued with the pregnancy. After consultations with the patient, her family, her doctors and the hospital’s ethics team the decision was made to go ahead with an abortion in order to save the mother’s life. Hospital president Linda Hunt said: “The hospital’s actions were consistent with our values of dignity and justice. If we are presented with a situation in which a pregnancy threatens a woman’s life, our first priority is to save both patients. “If that is not possible we will always save the life we can save, and that is what we did in this case. Morally, ethically, and legally we simply cannot stand by and let someone die whose life we might be able to save.”

However, because of this decision, the hospital was officially stripped of its Catholic affiliation by Bishop Thomas J. Olmsted because it “did not faithfully adhere to the ethical and religious directives for Catholic health-care services” (see footnote 12). The Bishop was also reported to have procured the sacking [of Sister Margaret McBride] from the ethics committee of the hospital for approving the decision and declared that she had “automatically excommunicated” herself because:

“While medical professionals should certainly try to save a pregnant mother’s life, the means by which they do it can never be by directly killing her unborn child. The end does not justify the means.”

In both these cases, as in Savita’s case, a decision to refuse treatment would have led to the death of the woman. This refusal must therefore be understood as prioritising the life of the fetus over and above the life of the pregnant women, even though the fetus had no chance of surviving to become a live baby.

According to Catholics for Choice, Bishop Olmsted made an error of interpretation of Catholic health policy in the Arizona case. However, their interpretation of what Catholic policy should be does not appear to be reflected in existing texts and statements made. Even on the evidence gathered for this paper, which is far from comprehensive and has mostly emerged through media reports since October 2012 and only because of Savita Halappanavar’s death, the refusal to terminate a pregnancy even when the woman’s life is at risk appears to be happening on three continents.

The life-saving value of termination of pregnancy in both wanted and unwanted pregnancies

Countries where abortion remains legally restricted and unsafe are almost always also countries where maternal deaths in wanted pregnancies are also still high. In other words, in those countries, the value of a pregnant woman’s life is low no matter whether the pregnancy is viable or not, or wanted or not. In the five Catholic countries where termination of pregnancy is not permitted even to save the life of the woman, this error of interpretation of Catholic health policy is even more likely to be a risk.

Member of the Irish parliament, John O’Mahony, who is said to have strong anti-abortion views, described Savita Halappanavar’s death as “a terrible tragedy” and said he thought it should not have happened even with existing legislation. “I am totally against abortion but also totally for protecting the mother’s life,” he said. Unfortunately, it is not possible to have it both ways, as all the cases reported in this paper show.

In response to a letter protesting Savita’s death from the International Campaign for Women’s Right to Safe Abortion, Eamon Gilmore, the Deputy Prime Minister of Ireland, went further:

“I do not think we, as a country, should allow a situation where women’s lives are put at risk in this way. We must deal with the issue and bring legal clarity to it… Six Governments in this State since the Supreme Court judgment in 1992 …have not dealt with it. This will not be the seventh.” (16 November 2012)

“… I can easily argue that Savita’s life was at risk the moment her membranes ruptured at 17 weeks. However, does Irish law mean a different kind of risk? And if so, how would doctors judge that risk to be present? Ruptured membranes and fever? Shaking chills? Bacteria in the amniotic fluid? Positive blood cultures? Sepsis? Cardiovascular collapse? How sick must a pregnant woman be in Ireland for a doctor to state that her life is at risk?”

This is a question that must be asked in more countries than just Ireland.

Is this the norm in Catholic maternity services?

The refusal to terminate the pregnancies of Savita Halappanavar and others described in this paper appears to have contributed to Savita’s death and put the lives of other pregnant women seriously at risk. If so, this is unethical and violates the Hippocratic oath to do no harm.

How many other health professionals who believe they are adhering to Catholic health policy are refusing to terminate such pregnancies or have been refused permission to do so because the fetus is still alive? Is this the norm across Catholic health services, and if so, in which countries, or are these exceptions? The governments of Ireland and of every other country with Catholic-run maternity services need to answer these questions urgently.

The ethical imperative to save pregnant women’s lives

Many of the events presented in this paper are recent or have only just taken place, and most of the sources are media and individual reports. However, there is a very worrying common thread across countries and continents. These reports invite rigorous investigation of treatment provided and outcomes for women of inevitable miscarriage, severe fetal anomalies, and other non-viable pregnancies, and pregnancies affected by serious illness that require a termination in at least a sample of Catholic maternity services and by Catholic health professionals in the countries where they work.

If research unearths more histories of failure to treat and save women’s lives, as in the cases reported in this paper, any such health professionals and/or hospitals should be stripped of their right to provide maternity services and emergency obstetric care. In countries where these are the only existing maternity services locally or nationally, governments should either: 1) refuse to fund these services, 2) take over these services, 3) make every effort to replace them with non-religious services, and/or 4) at the very least, require that non-religious staff are available at all times specifically to take charge of such cases to prevent morbidity and deaths.11

Finally, governments of countries with Roman Catholic-run maternity services should join with Catholic religious representatives to state categorically that neither the law nor Catholic health policy support the withholding of emergency obstetric care where a pregnant woman’s life and health may be at risk. Termination of pregnancy will end fetal life—whether done as emergency obstetric care, for an inevitable miscarriage or non-viable pregnancy, on grounds of severe fetal anomalies, when the continuation of the pregnancy presents a risk to the woman’s life or health, or when pregnancy is unwanted. By definition, it is always deliberate. At issue is whether the woman’s life comes first or not. This is the crux of what abortion—as well as emergency obstetric care —is all about.

Acknowledgements:Thanks to Goretti Horgan, Lisa Hallgarten, Toni Belfield, and Pathika Martin for very helpful comments on the text.

2. The most recent figure published by WHO is thought by experts in Ireland to be too low, as data are incomplete by WHO measures. Ireland is in the process of shifting to using the UK system of determining the maternal death ratio; figures are due in 2013. For 2009-2011 data see: Maternal Death Enquiry MDE Ireland.

9. It was also reported in the media that Savita had developed a serious infection, possibly via her dilated cervix, which caused sepsis and contributed to her death. This paper is not about what caused her death, however, but rather about why there was a delay in one aspect of her treatment, i.e. termination of the pregnancy.

11. The Obama government in the US has set a precedent for this in withdrawing a multi-million dollar contract from the US Conference of Catholic Bishops for refusing to provide contraception in a government-funded service to women who have been trafficked and who require a range of urgent treatments. This decision was upheld by a US federal court in 2012.

]]>http://rhrealitycheck.org/article/2013/01/22/interpretation-catholic-health-policy-and-consequences-pregnant-women/feed/2The Death of Savita Halappanavar: A Tragedy Leading to Long Overdue Change?http://rhrealitycheck.org/article/2012/11/18/death-savita-halappanavar-tragedy-leading-to-long-overdue-change/?utm_source=rss&utm_medium=rss&utm_campaign=death-savita-halappanavar-tragedy-leading-to-long-overdue-change
http://rhrealitycheck.org/article/2012/11/18/death-savita-halappanavar-tragedy-leading-to-long-overdue-change/#commentsSun, 18 Nov 2012 22:03:06 +0000

Hopefully, the tragedy of Savita will, at least, finally spur the Irish government to issue clearer guidelines that the life of the pregnant woman must be privileged over that of her fetus. But if the thousands demonstrating reflect changes already underway in Irish society—including a growing dissatisfaction with the Catholic Church’s influence—perhaps some day Savita Halappanavar will be remembered as the woman whose death was a turning point in the long struggle for the legalization of abortion in Ireland.

The tragic and unnecessary death of Savita Halappanavar—a 31-year old Indian woman who was denied a life-saving abortion in an Irish hospital—has sparked reactions across the globe. Thousands have marched in Dublin. Demonstrations have taken place in India and elsewhere. An international day of protest is called for November 21. Tense meetings between Indian and Irish government officials are taking place. The overriding question now is: what will be the legacy of this horrible event, beyond the unspeakable grief of Savita’s loved ones? After the demonstrations have stopped, will Irish hospitals—where abortion remains illegal but is permissible in life-threatening conditions—proceed differently in the future? Will the country finally move toward legalizing abortion?

This heartbreaking incident has led me to contemplate the long history of abortion struggles around the globe and under what circumstances, change takes place. It is not an exaggeration to say that throughout history millions of women have died and even more have been injured because of the lack of safe abortion. But only some of these tragedies capture the public’s attention and become catalysts for change. And sometimes public attitudes are affected even when a woman’s death is not involved.

Consider the history of abortion in the United States. Two events that occurred in the 1960s were instrumental in moving much of the country toward an endorsement of legal abortion. The first, in 1962, involved Sherri Chessen Finkbine, a Phoenix woman pregnant with her fifth child, who learned that the Thalidomide pills she had been using as a sleep aid were strongly associated with severe birth defects. Her doctor was able to arrange a “therapeutic” (i.e. approved) abortion for her at a local hospital, but Finkbine, in an act of decency that would prove costly, went public with her story as she hoped to warn other women who were in her situation. Her interview with a journalist created a media sensation, and nervous hospital authorities cancelled her abortion. Ultimately Finkbine, unable to find an abortion anywhere in the United States, obtained one in Sweden, where she delivered a fetus with missing limbs. Doctors told her the fetus would have had no chance of survival. Finkbine’s story spread beyond Phoenix to become a national story, including a cover on Life magazine. This incident, particularly the unprecedented visibility of abortion on the cover ofthe leading news magazine of the 1960s, “had a galvanizing effect on public opinion,” in the words of the journalist Linda Greenhouse, a longtime observer of the trajectory of abortion rights in the United States.

The second incident, which took place in 1966, had a similarly powerful effect, this time within the medical community. Nine highly-respected San Francisco doctors, affiliated with university hospitals, were abruptly threatened with the loss of their licenses because they had been performing hospital-based abortions on women infected with rubella, a practice that was increasingly common in a number of states by the 1960s, as evidence of the link between this disease and birth defects became known. The sudden decision to prosecute this decision apparently was instigated by one individual, a strongly anti-abortion member of the California Board of Medical Examiners. The case drew national media attention and an unprecedented show of support across the country; more than 100 deans of medical schools protested this prosecution, and ultimately the charges were dropped. A few years later, the American Medical Association reversed its longstanding position on abortion and voted, at its annual meeting, in support of a resolution calling for legalization.

In retrospect, we can see that these two incidents not only precipitated changes, both in public opinion and among medical professionals, but also reflected changes that were already underway in American society. A majority of the public then, as now, believed that women carrying severely compromised fetuses should have the option of an abortion. American physicians then were growing increasingly dissatisfied both with the numbers of needless death and injuries from illegal abortion and the lack of clarity as to which abortions actually were permitted exceptions to the overall ban. Sherri Finkbine and the fine San Francisco doctors offered a human face to these complex policy issues.

It is too soon to know what impact the case of Savita Halappanavar might have in the long run. What makes her case somewhat different from the two U.S. incidents mentioned above is that the law was already on her side; Irish law, as mentioned above, does permit abortion in life-threatening situations. The problem was that those caring for her in the Galway hospital were interpreting this law in an extremely rigid manner—by waiting for her fetus to no longer have a heartbeat before proceeding with an abortion, they were acting in accordance with the most orthodox reading of Catholic Healthcare Directives.

The reality is that what constitutes a “life-threatening” condition in various medical situations, including failing pregnancies, and how much time exists for medical professionals to intervene is very often not clear-cut. Till now, the Irish government has apparently given no guidance to hospitals as to how to proceed in such cases and doctors are fearful of prosecution. As Marianne Mollman of Amnesty International has written of her own investigation of this problem:

In 2010 I saw that the European Court on Human Rights berated the Irish government for not regulating access to life-saving abortion clearly, creating insecurity for medical providers and patients alike. In 2011 the United Nations Human Rights Council issued various recommendations to the same effect. …My research taught me that many medical providers in Ireland want clarity on when they can intervene and when they cannot.

Hopefully, the tragedy of Savita will, at the very least, finally spur the Irish government to issue clearer guidelines—guidelines that make clear to clinicians that the life of the pregnant woman must be privileged over that of her fetus. But if the thousands of Irish citizens demonstrating in the streets and pressuring their elected officials indeed reflect changes already underway in Irish society—including a growing dissatisfaction with the Catholic Church’s influence—perhaps some day Savita Halappanavar will be remembered as the woman whose death was a turning point in the long struggle for the legalization of abortion in Ireland.

Numerous questions have arisen in the wake of Savita's case. Why did this happen? Doesn't Ireland, a country with otherwise draconian abortion laws, allow abortion to save the life of the mother? Was there any doubt an abortion was necessary to save Savita's life? Can this happen in the United States? And here are my answers.

Last night, we reported on the unnecessary and tragic death of Savita Halappanavar, who entered an Irish hospital undergoing what turned out to be a miscarriage of a wanted pregnancy at 17 weeks, and was denied a life-saving abortion because, as she and her husband were told, Ireland is “a Catholic country.” Translation? Even a non-viable fetus, perhaps already dead but in any case absolutely certain not to survive, is more important than a woman’s life.

Numerous questions have arisen in the wake of this case.

One: Why did this happen? Doesn’t Ireland, a country with otherwise draconian abortion laws, allow abortion to save the life of the mother?

Two: Was there any doubt an abortion was necessary to save Savita’s life?

Three: Can this happen in the United States?

I’ll take these in turn.

The reason this happened is at once very simple and highly complex. It starts with Irish abortion law, and ends with the imposition of a misogynistic ideology on a woman literally begging for mercy from pain and for her own life as she pleaded with her doctors numerous times to perform an abortion on a fetus it was clear would not live.

Current Irish law on abortion is somewhat murky. The country’s laws, like those of most others, have shifted dramatically over the past two centuries, until in the mid-fifties abortion was made illegal in virtually all circumstances. The legal landscape changed again over 20 years ago when the Irish Supreme Court decided that women had a constitutional right to an abortion where there was “real and substantial risk” to the life of the mother. The Supreme Court decision came in response to the case of “X,” who, as a February 2012 article in the New York Times pointed out, was a 14-year-old girl prevented from leaving the country to have an abortion after she became pregnant from rape. After that decision, according to a Human Rights Watch (HRW) report:

abortion [in Ireland remained] legally restricted in almost all circumstances, with potential penalties of penal servitude for life for both patients and service providers, except where the pregnant woman’s life is in danger.

In its 1992 decision, the Irish Supreme Court also required the government to clarify the conditions under which a legal abortion might take place.

Nonetheless, as we reported in December 2011, Human Rights Watch found that 20 years later:

little legal and policy guidance [exists] on when, specifically, an abortion might be legally performed within Ireland. As a result, some doctors are reluctant even to provide pre-natal screening for severe fetal abnormalities, and very few – if any – women have access to legal abortions at home.

With no legal guidance and highly restrictive abortion laws, the government of Ireland was again taken to court in 2005, when according to AP, “the Irish Family Planning Association took Ireland’s government to court on behalf of three women who had to travel overseas that year for abortions: an Irish woman who had four previous children placed in state care, an Irish woman who didn’t want to become a single mother, and a Lithuanian woman living in Ireland who was in remission from cancer.”

In December 2011, the European Court of Human Rights ruled that Ireland’s strict law forbidding abortions even in dire circumstances violated the right to life of Mrs. C, the pregnant woman suffering from cancer. Based on arguments heard in that case, the17 judges of the European court arrived at an 11 to 6 verdict charging that Ireland was wrong to keep the legal situation unclear and that the Irish government “had offered no credible explanation for its failure.” Pursuant to that decision, a panel was formed and was supposed to deliver recommendations this past summer to finally clarify the abortion law, but the government still had not acted. Of course, now, in the wake of the global outcry that has erupted over Savita’s death, government officials are rushing to assure that “investigations are going forward.”

This situation leads me to the following conclusions: One, the Catholic Church, long influential in Irish politics and absolutely opposed to *any* softening of, or so-called exceptions to, the longstanding total abortion ban in Ireland (or anywhere for that matter) has almost certainly been lobbying to slow down the process of releasing the new guidance needed to clarify the law and policy. As a result, there is still lack of clarity in whether to allow abortions in cases where, for example, a woman has cancer but is not “on her deathbed,” or a young girl has tried to or is contemplating suicide because she was impregnated by rape. But there is absolutely no lack of clarity in the Irish Supreme Court’s decision that if a woman’s life is indeed in imminent danger, as Savita’s life so clearly was, she has a constitutional right to said abortion.

Two, the medical staff of the hospital denied Savita an abortion even though she was constitutionally guaranteed one to save her life because this was a Catholic hospital and therefore the (to me) questionable “conscience rights” of the institutional Catholic church, the hospital, its doctors, really, whomever was involved there, superceded the right to life of a living, breathing woman. In other words, the Church and its hospitals hold themselves outside the law. [And, it should be noted, they are pushing to expand so-called conscience provisions in U.S. law all the time, so their power over your life is widening.] In my analysis, then, while the government is indeed responsible for confusion in cases where “risk of death” is not quite clear, in this case there should have been no confusion at all as to what to do. What medical professional watches his or her patient in agony for days on end and does not act? One governed by misogynistic religious ideology.

Second question: Was there any doubt Savita needed an abortion? As this case has exploded, anti-choicers are out in force suggesting that perhaps she didn’t really need an abortion and would have died anyway. This question has also been raised by others, such as Dearbhail McDonald, the Legal Editor of IrishTimes.com, who wrote:

We simply do not know, at this early stage, what caused the septicaemia (blood poisoning) that led to her death or whether her death could have been avoided even if her unviable foetus had been removed much earlier.

Obstetrician-gynecologist and writer Dr. Jen Gunter puts such speculation to rest. She writes:

What does the standard of medical care say about this treatment? Without access to the chart, “miscarrying” at 17 weeks can only mean one of three things:

A) Ruptured membranes

B) Advanced cervical dilation

C) Labor (this is unlikely, although it is possible that she had preterm labor that arrested and left her with scenario B, advanced cervical dilation).

All three of these scenarios have a dismal prognosis, none of which should involve the death of the mother.

Gunter explains each scenario in detail (and I highly recommend you read the full piece) and then concludes:

As Ms. Halappanavar died of an infection, one that would have been brewing for several days if not longer, the fact that a termination was delayed for any reason is malpractice. Infection must always be suspected whenever, preterm labor, premature rupture of the membranes, or advanced premature cervical dilation occurs (one of the scenarios that would have brought Ms. Halappanavar to the hospital).

So no, there was no question what needed to be done. Contrast this, for example, with the case of my own father who, after a stroke of his abdominal aorta was in the hospital for nine months, during which doctors proposed surgery after surgery after procedure, none of which could guarantee a solution to the fundamental physical issues he faced, complications from which it was clear he would ultimately die. But they insisted on doing everything possible to keep him “alive,” until it became clear to me as his guardian that it was all simply prolonging his suffering. This is how we treat other illnesses in the United States that do not involve the words “woman” or “pregnancy;” we do everything medically possible for the patient to the point of pathology. In the case of a pregnant woman, anti-choicers want to wait to see autopsy results to figure out if she could have been saved.

Finally, can this happen in the United States? To answer this question is simple. It already is happening. In Texas, a state in which the governor and state legislature have what can only be called an obsession with undermining the health and rights of women, cuts to family planning funding and diminishing access to services are pushing desperate women into Mexico to buy drugs to self-induce abortion. Low-income women in states across the country are unable to get access to abortions for any reason, much less for rape, incest, health, or life. So-called 20-week abortion bans based on medically disproven assertions that 20-week old fetuses feel pain (they do not) are working their way through the courts and would result in denial of abortion care to women who miscarried or faced risks to their health or lives, not to mention fetal anomalies or infections of the kind that killed Savita. Personhood amendments seek, quite literally, to declare fertilized eggs to be persons, and women… not to be persons. As I wrote yesterday, no legislative prospect quite excites the GOP-dominated U.S. House of Representatives more than an effort to ban abortion outright or to eliminate funding for contraception, breast and cervical cancer prevention, and other forms of sexual and reproductive health care. These are but a few examples, and others abound. We devote this website to them. Moreover, it is no secret that Catholic hospitals are gobbling up other hospitals throughout the country, leaving an increasing number of women vulnerable to ideologically-based “treatment” when their lives or health may be at risk. Taken together, these conditions are increasingly creating circumstances in which women do not have access either to the means to prevent or plan pregnancy, nor the means to end a pregnancy.

In response to Savita’s death, Sky Newsreported that: “Her death is expected to spark a backlash against the Irish government, criticised by left-wing members of parliament for failing to introduce new laws to permit abortion in life-threatening circumstances.”

For her, that backlash is too late. For the millions of women and girls around the world still living, it is not. Start demonstrating, start protesting, start telling your representatives that this will not stand. I do not want to lose my daughter to a medical system and government ruled by misogyny and ideology. No one should have to. We can stop this now. It is up to us.

A report released today details how the public health emergency in eastern Burma continues to undermine the health and well being of millions of people affected by decades of war. Women in eastern Burma face the worst pregnancy outcomes anywhere in Asia, and access to contraception is virtually nonexistent.

Though the historic ceasefire in Burma between the government and the Karen National Union (KNU) has been called into question, the nation is continuing to move rapidly through a series of astonishing changes. After 60 years of internal conflict, 651 political prisoners were released from Burma’s prisons this past month, including both convicted military leaders and prisoners of conscience. Aung San Suu Kyi, the Nobel Peace Prize-winning opposition leader formerly under house arrest is running for parliament in Rangoon. President Thein Sein is urging Western nations to remove sanctions on Burma.

But “Separated by Borders,” a report released last week from Ibis Reproductive Health and the Global Health Access Program, details how the public health emergency in eastern Burma continues to undermine the health and well being of millions of people affected by decades of war. The resulting decay of healthcare-related infrastructures and a long legacy of human rights violations—including the military’s policy of denying health care to certain ethnic groups—have all taken their toll. Burma’s maternal mortality rates now dwarf the rates in Thailand and Burma (Myanmar) as a whole, leaving women in eastern Burma with the worst pregnancy outcomes anywhere in Asia.

Access to contraception is virtually nonexistent: an estimated 80 percent of women in eastern Burma have never used birth control. This naturally results in high numbers of unplanned pregnancies. Post-partum hemorrhage and unsafe abortion are the leading cause of maternal mortality for Burmese women. Small wonder given the scarcity of hospitals, the difficulty of traveling through conflict zones, and the generally low priority given to women, period, let alone when they are pregnant.

Dr. Angel Foster, an affiliated scholar with Ibis and one of the report’s authors, is returning to the region this week to support the training of local health workers.

“Too often, those working with refugees, migrants, and cross-border populations in Thailand do not coordinate a common standard of service,” she explained. “The patchwork practice leads to misinformation among Burmese people.”

Dr. Foster offers emergency contraception as a prime example. It’s key to preventing unintended pregnancies, which is particularly important given the high rate of sexual assault in the immigrant camps along the Thai/Burma border. But some clinics only provide EC to patients if they can document that they are assault victims; others do not provide EC to teenagers, or unmarried women. “If you happen to go to one of the clinics where you don’t get it, you tell your friends about that experience, and they don’t know that other organizations will make EC available,” Dr. Foster said. “People aren’t asking for it because they don’t know it’s possible.”

Now that the European Union has lifted its ban on travel to Burma, human rights organizations will once more have the opportunity to bring first-world reproductive health care to the region. Cari Siestra, a lawyer and the report’s co-author, hopes the unprecedented information collected in “Separated by Borders” will assist the outside groups moving towards providing aid to eastern Burma. “The time has come to rebuild the health and human rights of the millions of men, women, and children affected by this conflict,” she said.

Both Foster and Sietstra believe that the reproductive health emergency must be a priority during this period of transformation. Said Foster:

“When women don’t have control over their fertility, when to have a child and how many, it limits their ability to fully participate in political life, or in wage employment, or in education opportunities.”

Sietstra adds, “Women’s autonomy is tied to their reproductive choices. If the families of eastern Burma are to return to health and wellness, women and families absolutely need to control fertility – to choose whether or not to have a child, and to have access to services that allow them to have a child safely.”

Thirty-eight of 58 countries surveyed may fail to meet their target of 95 percent coverage by skilled attendants by 2015 unless an additional 120,000 midwives are trained, deployed and retained. A new report also indicates that upgrading midwifery services could save more than 3.6 million lives each year by 2015.

“I lost my baby because of the neglect of a midwife who attended to me. I was told to go the toilet and gave birth in the toilet,” said Christine Kabwe (not her real name).

When a woman is pregnant in Africa, it is assumed she has one foot in the grave and that her chances of being alive after birth are very slim.

Many mothers fear giving birth at a health facility, said Madame Callista Mutharika, first lady of Malawi, in her keynote address at the International Confederation of Midwives (ICM) 29th Triennial Congress, taking place in Durban South Africa.

Cultural traditions, a lack of sensitivity and poor treatment by midwives discourage women from accessing health services, she said, even where they are available. She reminded all midwives to remember the oath each one of them took when they started their job.

“The State of the World’s Midwifery 2011: Delivering Health, Saving Lives,” a major report released at the Congress, says that women have cited a variety of abusive behaviours at clinics and hospitals as reasons for choosing the more perilous route of home birth. In some cases the provider does not speak the local language, or female providers may not be available when wanted.

In his forward to the report, Secretary General of the United Nations Ban Ki-moon wrote that there is need to ensure that every woman and her newborn have access to quality midwifery services which demands taking care of bold steps to build on what has been achieved so far across communities, countries, regions and the world..

“Our responsibility is clear we must safeguard each woman and child so they may live to their full potential,” said Ban Ki-moon.

One of the most important investments a country can make to reduce high rates of maternal and infant mortality is in human resources to ensure women have access to skilled care, particularly midwives, during labour and delivery.

“The report points to an urgent need to train more health workers with midwifery skills and ensure equitable access to their life saving services in communities to improve the health of women and children,” said Dr Babatunde Osotimehin, Executive Director United Nations Population Fund (UNFPA).

According to the report, 38 of 58 countries surveyed might not meet their target to achieve 95 percent coverage of births by skilled attendants by 2015, as required by Millennium Development Goal (MDG) 5 on maternal health, unless an additional 120, 000 midwives are trained, deployed and retained in supportive environments.

The new report also indicates that upgrading midwifery services could save more than 3.6 million lives each year by 2015 in the 58 developing countries surveyed.

“Each year, 358,000 women die while pregnant or giving birth, some 2 million newborns die within the first 24 hours of life and there are 2.6 million still births, all because of inadequate or insufficient health care,” says the report.

“There has never been a report like this,” said Bridget Lynch, president of ICM, noting that it had been supported by more than 30 agencies whose collective aim is to strengthen midwifery practices to prevent maternal death and disability and improve the health of newborns, families and the entire communities.

“The biggest challenge however remains the shortage of midwives,” said Lennie Kamwendo, chair of the board of trustees of the White Ribbon Alliance for Safe Motherhood in Malawi.

Meanwhile, Dr Joy Lawn, director of global evidence and policy with Save the Children, asked midwives to use the data in the report for advocacy. She said increasing women’s access to high quality midwifery services has become a focus of global efforts to realize the right of every woman to best possible health care.

The report makes a series of recommendations to governments, regulatory bodies, educational institutions, professional associations and international organizations that would help remedy these problems and reinforce the status of midwifery in the countries surveyed.